Healthcare Provider Details

I. General information

NPI: 1184823114
Provider Name (Legal Business Name): PRIMARY CRITICAL CARE MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2007
Last Update Date: 02/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 S BUENA VISTA ST
BURBANK CA
91505-4809
US

IV. Provider business mailing address

PO BOX 998
NORTH HOLLYWOOD CA
91603-0998
US

V. Phone/Fax

Practice location:
  • Phone: 818-843-5111
  • Fax: 818-843-0641
Mailing address:
  • Phone: 818-509-2222
  • Fax: 818-509-2229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberG42382
License Number StateCA

VIII. Authorized Official

Name: DR. BRUCE T GIPE
Title or Position: PRESIDENT
Credential: MD
Phone: 818-509-2222